The document discusses complications that can arise from radial artery access for cardiac catheterization procedures. It describes specific radial complications such as spasm, dissection, perforation, hematoma, and pseudoaneurysm. Risk factors and preventative measures are provided. Management strategies for complications like spasm, entrapment, and perforation are outlined. The conclusion states that radial complications are rare but can be anticipated and addressed through early recognition and appropriate action.

1. Management of Basic Radial
Complications: What to Expect and
How to Get Out of the Woods
Robert De Larochellière, md, FRCPC

2. I, Robert De Larochellière, don’t have any
relevant financial interest to declare.

3. Adoption of Radial Access and Comparison of Outcomes to Femoral
Access in Percutaneous Coronary InterventionClinical Perspective
Unadjusted rates of the primary outcomes of r-PCI and f-PCI.
Feldman D et al. Circulation 2013;127:2295-2306
Copyright © American Heart Association

4. Specific transradial complications

5. Gray's Anatomy of the Human Body, 1918

6. Radial pulse oxymetry

7. « In the evaluation of
hand collaterals, PL
and OX were found to
be more sensitive
than MAT. When
applied to transradial
approach screening,
only 1.5% of patients
were not suitable
candidates for the
transradial
approach »
Barbeau & al., Am Heart J. 2004 mar; 147(3);489-93

8. Acute Hand Ischemia After Radial Intervention in
Patient with CREST-Associated Pulmonary
Hypertension: Successful Treatment With Manual
Thromboaspiration
« Physical examination findings included sclerodactyly, Raynaud phenomenon, and diffuse
telangiectasias »
« During hospitalization, the patient underwent TR coronary angiography in the context of
screening examinations. The pre-procedure evaluation revealed a good palpable right
radial pulse. No evaluation of ulnar artery patency was performed. International
normalized ratio (INR) was 1.8. This finding along with female gender and small body size
were perceived to increase the risk of bleeding associated with femoral access »
Taglieri &al., J INVASIVE CARDIOL 2013;25(2):89-91

9. Radial artery spasm: predisposing factor
Patient related
• Female sex and younger age
• Small body size
• Diabetes mellitus
• Smaller radial artery
diameter
• Vessel tortuosity
• Anxiety
Procedure related
• Unsuccessful access
attempts
• Pain
• Vascular trauma (wire)
• Larger sheath
• Number of catheter and
procedure duration

10. Radial artery spasm management
• Adequate analgesia & atraumatic puncture
• Sedation (midazolam/narcotic) & warmth
• Smooth wiring of the vessel: size vs support, no force,
constant motion
• Gentle sheath insertion: small size, good tapering,
hydrophilic sheath
• Vesssel cocktail: verapamil 2,5-5 mg ± ntg 200 μgm ±
SQ ntg
• Vessel navigation: J-wire & soft wire, angio guidance &
visualisation, gentle loop management, « wire less »
multipurpose catheter, sheatless catheter

11. Radial spasm & avulsion
Courtesy of G.Barbeau

12. Tortuosity, kink and catheter entrapment

13. Catheter entrapment
Ju-Youn Kim & al., J INVASIVE CARDIOL 2012;24(1):E3-E4

14. Catheter entrapment
Ju-Youn Kim & al., J INVASIVE CARDIOL 2012;24(1):E3-E4

15. Avoid catheter entrapment
• Be cautious in tortuous anatomy
• Keep wire within the catheter while torking
towards the coronary ostia
• Check for kink if lack of distal responsivness to
manipulation
• Keep the catheter in large vessel if kink
• Gently try to counter the kink and re-wire the
catheter (0,014/ hydrophylic)

16. Hematoma, perforation,compartment syndrome
• Anticoagulation state
• Small vessel, small BMI, women,diabetic,
older patients
• Spasm,tortuosity & remmants radial artery
• Hydrophilic guidewire: perforation with chest
hematoma reported

17. Eurointervention, 2013

18. Hematoma, perforation,vessel occlusive
dissection
Avoidance:
•No force
•Angiographic/fluoroscopy guidance
•0,014 guidewire trough challenging tortuosty and
straitghtening by pullback
•J wire, Soft wire (Bentson, coronary) , Direct
« wireless » 4-5 F soft tip multipurpose catheter,
Balloon assisted tracking
•Carefull with hydrophilic 0,35 wire in the forearm

19. Courtesy of S.Rinfret

20. Perforation management
Ongoing procedure
•Soft guide wire under angio guidance
•Low pressure injection to image
•Optimal upsizing of catheter over the wire (6F) to
assure sealing
•BP cuff inflation 20 mmhg under SBP after
catheter passage
•Consider partial (50%) reversal of heparin if
massive at end of procedure

21. Perforation management
After procedure
•Angio control (low pressure injection)
•BP cuff inflation to 20mmhg under SBP
•Elastic band
•If low in forearm, consider 2nd compression
device on artery trajectory

22. In our center, with close to 100K
radial procedures, 3 patients with
compartment syndromes needed
surgery and had full recovery
Tizon H, Barbeau G, J Interv Cardiol 2008

24. Radial Arterio-venous fistula
Dehghani & al., J Med Case Reports. 2013;7(21)

25. Radial artery pseudoaneurysm
Presumed risk factor: oral anticoagulation, inadequate radial compression,
hypertension
Management: prolonged compression, thrombin injection under echo guidance,
rarely surgery

26. Heparin and RAO
Spaulding et al
Bernat et al
Courtesy of SV.Rao

27. Anticoagulation
Patent hemostasis
Rao SV. JACC Intv 2012
UFH 70-100 u/kg
UFH 70 u/kg
UFH 70 u/kg
Or Bivalirudin
UFH 50u/kg
UFH 70-100 u/kg
No
No
No
Yes
Yes
UFH 5000 u
Yes +
Ulnar compression

28. conclusion
• Specific radial access complications are rare
and can be anticipated in most instances
• Early recognition and action for vascular
complication can prevent further clinical
sequalae
• Radial access is the best mean to accomplish
the clinical goal of cardiac cath but is not the
only one to be master and use